As patient care organizations across the country delve into population health work, physician leaders are finding that data-driven projects aimed at improving adult immunization rates can be an effective area to target to improve the health of patient populations, while also producing significant clinical quality improvements.
Every year, an estimated 1 million older adults contract pneumococcal pneumonia and five to seven percent will die, according to data from the AMGA Foundation, the research arm of the Alexandria, Va.-based American Medical Group Association (AMGA). Further, pneumococcal disease accounts for $3.5 billion in direct medical costs, and pneumococcal disease in patients 65 and older accounts for the majority of the $3.5 billion, the most severe cases, and nearly 2 million hospital days each year.
To address gaps in its adult vaccination rates, The Iowa Clinic, a West Des Moines-based multispecialty practice serving central Iowa, initiated an analytics-driven collaborative project to increase immunization rates in adult patients, with a specific focus on pneumococcal pneumonia and influenza immunizations. The Iowa Clinic is the largest physician owned multi-specialty group in central Iowa, with more than 200 healthcare providers practicing in 40 specialties. The medical group serves a population area of 1.1 million people, averaging 400,000 patient visits each year.
“We understand, clinically, the cost economics of healthcare, with an ounce of prevention worth many pounds of cure, and when patients receive vaccinations, it greatly reduces the chances of those patients getting influenza or pneumococcal, which can be life-threatening and can result in costly hospitalizations,” Christi Taylor, M.D., chief quality officer, internal medicine at The Iowa Clinic, says.
The Iowa Clinic’s initiative to target adult immunizations was part of the AMGA’s Adult Immunization (AI) Best Practices Learning Collaborative, a 14-month, shared-learning collaborative facilitated by the AMGA Foundation. The pilot involved seven care provider groups working to identify optimal and efficient ways to improve adult immunizations and leveraging the Optum One population analytics platform to support the initiatives.
Data from Optum One indicates that, prior to the collaborative, the median pneumococcal pneumonia vaccination rates across all the participants in the pilot program was 60 percent for adults 65 years old and older, and 16 percent for high-risk adults ages 18 to 65. This is well below the Healthy People 2020 goals, which are 90 percent for adults aged 65 years and older and 60 percent for high-risk adults. The Healthy People 2020 goal for influenza vaccination is 90 percent for both populations.
Across the country, adult immunizations rates are considerably lower than childhood rates. “People are used to giving vaccines to children, particularly with pediatrics and family medicine, but adult vaccines often don’t receive the same attention,” Taylor says. “It’s not that you don’t care as an organization, but when people come in with 15 different things that you need to go through, it’s easy for [immunizations] to be pretty far down on the list.” Taylor also notes that with pediatric and young adult patients there are certain milestones, starting school or going to college, that serve as hard-stop reminders of particular vaccinations, yet there are no such milestones with adult patients. “From a physician’s standpoint, adult vaccines are something that you medically understand that it’s important, but you may be missing at a routine visit,” she says.
A key step in this initiative was establishing an AI team at The Iowa Clinic, which included Taylor, the chief medical officer, the direct of care management and quality, a care manager and physicians from internal medicine, family medicine, cardiology, OB/GYN and pulmonology. The team then designed and implemented strategies to identify and address gaps in recommended vaccination practices using intervention tools that target care providers and patients. Another key step was combining data and analytics with population health management techniques. The Iowa Clinic has a business relationship with Optum Analytics and uses an Allscripts electronic health record (EHR) system, and members of the AI team utilized those tools to gather the relevant data.
One critical component to the success of the project was leveraging objective evidence and ongoing reporting to motivate staff throughout the collaborative, according to Andrea Sorensen, clinical analytics director at The Iowa Clinic. “Going after the doctors and saying, ‘We are part of this collaborative and you need to do a good job with this,’ wasn’t enough. We had to put numbers in front of them to show them how they are doing,” Sorensen says. “And, we are very transparent in how we do that, so if there is a doctor who is lagging, it’s transparent, and nobody wants to be a C student, everybody wants to be on top. So that transparency helped drive the success of the program. We produced weekly and monthly reports for the physicians, their staff and care managers to make sure that everybody who could potentially touch that patient that was missing an immunization was aware of what was going on and had the data sitting in front of them.”
Taylor agrees, adding, “The frequent reporting and having up-to-date results were very helpful, particular for nursing staff. We were able to have weekly huddles and show them their progress, and their vaccination rates from the immediate week prior. If someone’s vaccination rates really plummeted one week, we were able to get on top of that within days and say ‘What’s going on? Why are we falling down on this?’ You could use that frequent feedback to direct behavior change and as part of education for the physicians and staff.”
According to data provided by AMGA’s AI collaborative, prior to the intervention, 55 percent of The Iowa Clinic’s patients age 65 and older had received at least one pneumococcal pneumonia vaccination, while 11 percent of the high-risk patients age 19 to 64 had received at least one vaccination. In the 14-month period that the Iowa Clinic participated in the collaborative, the organization saw its pneumococcal vaccination rates among the 65 and older patient population increase 21 percent, achieving a 77 percent immunization rate. Among high-risk adult patients in the 19 to 64-year-old population, The Iowa Clinic increased the pneumococcal vaccine rate to 22 percent, a 10.8-percent increase. Influenza immunization rates increased by 15 percent to an overall rate of 49 percent.
Increasing the immunization rate among the high-risk, under 65 population continues to be an area of focus, Taylor says. “That’s a population that is the least likely to be vaccinated, because they are younger. There are commercials telling people 65 and older to get their vaccine. It’s easy in a younger population to, frankly, just overlook it, and so, as much as they greatly need it, they might be the least likely to actually receive it,” she says.
The Iowa Clinic
In addition to the ongoing reporting, Taylor says the organization also utilized a dashboard tool embedded in its Allscripts EHR to provide visual reminders to providers and clinical staff. “That is helpful at the point of service when the patient is seeing the provider as either the doctor, nurse practitioner or nursing staff can open up the dashboard and just see, at a quick glance, if that patient is due for a vaccine. It’s very easy in a busy clinical day just to focus on addressing the eight other things that the patient came in for, so the visual reminder that the patient is due for a vaccine was very useful.”
Sorensen says the behavior changes among physicians and clinical staff have been sustainable, due in large part to the ongoing metrics reporting and workflow changes, and providers are continuing to focus on this population health work. Additionally, The Iowa Clinic will be reporting these measures to the Centers for Medicare & Medicaid Services’ (CMS) Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS), as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). “When you look all the different measures and metrics that are available as part of the [MIPS] program, the flu shots are also measures in that program, so it makes sense since we were so successful with the 65+ population as part of this collaboration, it was one of those measures that we’re doing well on, so we’re going to continue to focus on it as part of MIPS and MACRA measures,” she says, adding, “So, all our hard work will continue because it needs to be a normal part of business.”
Taylor says there were a number of important lessons learned during the 14-month collaborative project. “One of the steep learning curves for our clinical staff and providers was, inherently, the limitations of population health, in that, when you do massive outreach to hundreds of thousands of people at once, while it’s efficient, it’s not going to be razor specific,” she says. To that point, the practice utilized an automated outreach tool contact patients by telephone who had been identified as needing an updated vaccination and those patients received automated notification messages.
The challenge with that kind of large, automated outreach, Taylor says, is that there can be errors with the wrong patients receiving notifications that do not need to be notified. “With this kind of large outreach, as part of population health management, you need to accept that it isn’t perfect. In retrospect, we should have educated the physicians about that part of the process, that while 99.9 percent of the patients who are contacted will be the right ones, there’s going to be 100 people who will receive notifications who didn’t need to and they called the doctor’s offices and the doctors don’t know why they called. So we need to communicate with patients and doctors about the outreach and what it’s based on,” she says.
According to AMGA, the AI Best Practices Learning Collaborative, which was supported by Pfizer, significantly improved adult vaccination rates for all seven organizations in a little over one year, as measured against a group of similar providers. One focus of the overall collaborative centered on the new CDC guidelines for pneumococcal vaccines in patients age 65 and older. After 14 months, immunization rates in patients aged 65 and older increased from 4 percent to 34 percent. This absolute increase of 30 percentage points compares to an increase of 21 percentage points for a matched cohort of care providers in other organizations that are focused on population health but did not participate in the collaborative, according to AMGA. Based on the success of this collaborative, AMGA Foundation plans to launch an expanded collaborative this year that will involve up to 40 care organizations.